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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 04/14/2022
Date Signed: 04/14/2022 03:23:02 PM

Document Has Been Signed on 04/14/2022 03:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOUNTAIN VIEW CENTERFACILITY NUMBER:
197801605
ADMINISTRATOR:LAURA HERNANDEZFACILITY TYPE:
740
ADDRESS:715 WEST BASELINE ROADTELEPHONE:
(909) 626-6633
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 40CENSUS: 16DATE:
04/14/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Laura HernandezTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Case Management visit to ensure the Accusation/CDSS No. 6221326301D was posted as required by law, and that the residents, the residents' responsible parties, and the Local Long Term Care Ombudsman have been notified of the Accusation. LPA met with Laura Hernandez and discussed the purpose of today's visit.

At 10:30 A.M., LPA conducted a physical plant tour of both, the front and back buildings and did not observe the Accusation posted. Laura Hernandez showed LPA all postings and the Accusation was not posted. Ms. Hernandez confirmed that the Accusation had not been posted. As of today, residents, their responsible parties and Local Long Term Care Ombudsman have not been provided a copy of Accusation/CDSS No. 6221326301D. A notice will be issued to all required parties by 04/18/2022.

Health & Safety Code Section 1569.38 does require the licensee to provide written notification to a resident, the residents' responsible party, if any, and the local Long Term Care Ombudsman within 10 days from the date indicated on the Accusation. The licensee is also required to post the Accusation in a conspicuous location, written in at least 14-point type, stating that legal action is being taken against the facility to revoke the license. A copy of this section of Health and Safety Code was provided to Laura Hernandez. At 11:15 A.M., Ms. Hernandez showed LPA the Accusation that was received and posted it in a conspicuous location. The written notification to the above parties remains pending.

Civil penalties shall be assessed against any facility which fails to take corrective action within described time periods. Per California Health and Safety Code section 1569.38, you are hereby notified that a $100 civil penalty per day will be assessed until the violation is corrected. This assessment will not exceed $100/day regardless of the number of notices the licensee fails to send. The total civil penalty for a continuous violation shall not exceed $5,000. ***REFER TO LIC 809C for the continuation of this report***
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2022 03:23 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 04/14/2022 at 11:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOUNTAIN VIEW CENTER
FACILITY NUMBER: 197801605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2022
Section Cited
HSC
1569.38(b)(1)

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Posting of licensing reports; disclosure to new residents. (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events:
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Assistant Administrator posted the Accusation in a conspicuous location in the facility prior to LPA's departure today.

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(1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. This standard is not met as evidence by: LPA toured facility grounds with Laura Hernandez and did not observe the Accusation to be posted. Ms. Hernandez also confirmed that the Accusation had not been posted.
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PENDING: Licensee shall provide written notification of Accusation to residents, resident's responsible parties, and the Long Term Care Ombudsman by due date of 04/18/22 and provide proof of given notification to LPA Irra by 04/18/22.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW CENTER
FACILITY NUMBER: 197801605
VISIT DATE: 04/14/2022
NARRATIVE
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APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement concerning the proper application of licensing laws and regulations with the licensing agency. When civil penalties are involved, the licensee may request a formal review by the licensing agency to amend, extend the due date, or to dismiss the penalty. Requests for civil penalty appeal must be in writing, must be postmarked within 10 days of receipt of this form, and must be addressed to the Regional Office or licensing office with jurisdiction over the facility. The agency has a duty to review the facts presented without prejudice within a 10-day period. Upon review of the facts upon which the appeal is based, the agency may amend any portion of the action taken, or may dismiss the violation.

The licensing agency review of the appeal may be conducted based upon information provided in writing by the licensee. The licensee may request an office interview to provide additional information. The licensee will be notified in writing of the results of the agency review.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited per Health & Safety Code Section 1569.38 (Refer to LIC 809-D).

Citations, civil penalties, and appeal rights were discussed.

Exit Interview was conducted with Assistant Administrator Laura Hernandez and a copy of the report was issued.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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